Liver Pathology - Abd Son Test 2

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crossword terms & lecture slideshow

fibromellar carcinoma

a subtype of hepatocellular carcinoma that is found in adolescents and young adults without coexisting liver disease

core biopsy

a procedure in which a small piece of tissue is removed from an organ in order to examine it under a microscope. usually done to rule out malignancy of a tumor.

cholangiocarcinoma

a malignant (cancerous) growth in one of the ducts that carries bile from the liver to the small intestine. also known as bile duct cancer

fine needle aspiration

a procedure in which a thin needle is placed into a tissue or organ. cells are acquired by drawing them up into a syringe

lipoma

a benign tumor composed of fat

hypervascular

term that means "demonstrating excessive color flow when evaluated with color doppler."

microbubble enhanced sonography

the injection of a contrast (which consists of microbubbles in a suspension) for the purpose of enhancing the visualization of the vascularity of a mass on sonography

hemangioendothelioma

a true neoplasm of vascular origin, characterized by proliferation of endothelial cells in and about the vascular lumen; it is usually considered to be intermediate in grade between hemangioma and hemangiosarcoma but sometimes is used to denote the latter.

focal nodular hyperplasia

known as FNH, this is the 2nd most common benign mass of the liver

hemangioma

a benign tumor composed of blood vessels

hepatocellular carcinoma

accounts for the majority of all primary liver cancers. this type of cancer occurs more often in men than women, usually in people 50-60 years old. the disease is more common in parts of Africa and Asia than in north or south America and Europe. most common cause in America is alcoholic cirrhosis.

contrast agent

a substance injected into the blood stream that increases the contrast between tumors and normal liver tissue, making them more visible

angiomyolipoma

a benign tumor composed of blood vessel endothelium, smooth muscle tissue, and fat.

spelt

single-photon emission computed tomography (a special type of CT scan)

karposis sarcoma

a rare type of cancer seen in patients with immune deficiency. mainly seen in patients with AIDS.

candidiasis

a fungal infection by candida albicans (also known as thrush)

Glycogen

this is stored energy. it is made primarily by the liver and the muscles, but can also be made by glycogenesis within the brain and stomach. it is stored in the liver and when energy is needed it is converted into glucose and released in the blood.

pyogenic

refers to bacterial infections that make pus.

normal variant

an unusual property of an organ or tissue (ie shape, size, or form) which usually does not cause medical problems for the patient.

Liver Function Tests

include direct bilirubin, indirect bilirubin, serum protein, albumin, beta globulin, Alkaline Phosphate (ALP), Alpha Fetal Protein (AFP), Aspartate Aminotransferase (AST)/Serum Glutamic Oxaloacetic Transaminase (SGOT), Alanine Aminotransferase (ALT)/Serum Glutamic Pyruvic Transaminase (SGPT), cholestero, Lactic Dehydrogenase (LDH), and Prothrombin Time (PTT)

echinococcus granulosis

this is the parasite that causes hydatid disease (tapeworm 3-6mm long) most common in sheep and cattle herding countries.

situs inversus

a variant or anomaly in which the organs are located (by varying degrees) on the opposite side of the body

autosomal dominant traits

traits that are expressed if present on one gene. only one parent has to have the trait to have a child with the same trait

surgical jaundice

this type of jaundice occurs due to an obstruction of bile flow out of the liver which causes it to spill over into the blood.

liver flukes

Flatworms that can occur in bile ducts, gallbladder, and liver parenchyma. they feed on blood. adult flukes produce eggs which are passed into the intestine. it respires anaerobically. its life cycle contain two hosts: sheep and snail.

E.Coli

a bacteria that is commonly found in the lower intestine of warm-blooded organisms

TIPS

a shunt used in patients with portal hypertension. it connects the right portal vein to the right hepatic vein in order to relieve pressure in the portal vein system.

abscess

a collection of pus (dead neutrophils) that has accumulated in a cavity formed by the tissue in which the pus resides on the basis of an infections process (usually caused by bacteria or parasites or other foreign materials.

hamartoma

a benign, focal malformation that resembles a neoplasm in the tissue of its origin. this is not a malignant tumor, and it grows at the same rate as the surrounding tissues. it is composed of tissue elements normally found at that site, but which are growing in a disorganized mass. they occur in many different parts of the body and are most often asymptomatic and undetected unless seen on an image take for another reason.

Ringdown

an artifact commonly seen in the presence of gas. It appears as bright white vertical lines on the US images. See in cases of biliary hamartoma from the cholesterol crystals that are trapped in the mass during development.

diffuse hepatocellular disease

a disease that involves the entire liver

omphalocele

a type of abdominal wall defect in which the intestines, liver, and occasionally other organs remain outside the abdomen in a sac because of a defect in the development of the muscles of the abdominal wall

incubation period

the time elapsed between exposure to a pathogenic organism, a chemical, or radiation, and when symptoms and signs are first apparent

compensatory hypertrophy

the enlargement of an organ (or part of an organ) due to damage or agenesis of an organ (or part of an organ)

hypoglycemia

low blood sugar

anomaly

a discrepancy or deviation from an established appearance or shape. these may eventually cause problems for the patient.

autosomal recessive traits

traits not expressed unless the gene is present on both autosomal chromosomes. both parents must be carriers to produce a child with this type of hereditary disease.

varices

enlarged distended veins

hyperglycemia

elevated blood sugar

medical jaundice

this type of jaundice occurs due to hepatocellular disease

agenesis

failure of an organ to develop during embryonic growth and development

recannalization

re-opening of a vein such as the paraumbilical vein in the liver

target lesion

a bull's eye lesion composed of rings of varying echogenicity resembling a bull's eye pattern

diaphragmatic slip

occurs when the diaphragm invaginates into the liver during embryological development and remains stuck there

cavernous transformation

multiple tube-like structures appearing around the portal vein which represent collaterals in the presence of portal vein obstruction or impedance to portal vein flow into the liver

triglycerides

an ester derived from glycerol and three fatty acids. it is the main constituent of vegetable oil and animal fats

schistosome

a parasite commonly known as blood-flukes and bilharzia, includes flatworms which are responsible for the most significant parasitic infection of humans by causing the disease schistosomiasis.

collateral circulation

an alternate route for blood flow when the primary artery or vein is blocked

accessory fissure

an in-folding of peritoneum into the liver.

Complete Agenesis of Liver

incompatible with life

With Right Lobe Agenesis,

Caudate lobe is usually also absent

What is result of agenesis of a lobe?

Compensatory Hypertrophy of remaining lobe

Congenital Diaphramatic Hernia

varying amounts of liver herniated into the thorax

Do development anomalies affect LFTs?

NO - except for total agenesis b/c there wouldn't be any

Most common location for accessory fissure?

inferior accessory fissure - stretches from RPV to inferior surface of the R lobe of Liver

How many fissures = accessory fissure

more than 4

Are accessory fissures common?

NO

What do diaphragmatic slips look like on US?

Accessory fissures or pseudomass

3 types of Vascular Anomalies

Variations in the
1. Hepatic Artery
2. Hepatic Veins
3. Portal Vein

Do vascular anomalies affect LFTs?

Not usually

True liver cysts are believed to result from

defects in the bile duct formation

Can patient develop a true cyst in liver?

NO - they are congenital (born with it)

Can patient develop a cystic mass in liver?

Yes

What are causes of cystic masses in liver?

trauma, parasites, inflammatory change (i.e. hepatitis)

Where do liver cysts typically occur?

Right Lobe

True liver cysts contain

clear serous fluid & bile duct epithelial lining

Appearance of liver cyst

anechoic, round or oval
thin well defined wall
good thru transmission

Large liver cysts can cause

liver enlargement
biliary obstruction and /or
epigastric pain
(bleeding & infection also cause pain)

Do LFTs elevate with liver cysts?

NO

Liver cysts most commonly seen in patients

over 80 yrs old

Will liver cysts recur?

Yes if not removed or ablated

Hemorrhaged cysts will appear

to have internal echoes,
septations,
a thick wall
may appear solid or have solid components (complex)

Peribiliary cysts are usually seen in patients with

severe liver disease

Size of prebiliary cysts?

small, .2-2.5 cm

Location of prebiliary cysts

porta hepatis, junction of RHD & LHD

Prebiliary cysts may cause

Biliary Obstruction

Sono appearance of prebiliary cysts

Discrete cluster cysts
tubular anechoic areas paralleling bile ducts & PV

On doppler, prebiliary cysts...

demonstrate no flow

Prebiliary cysts impact on LFTs?

No elevation unless biliary obstruction

Types of polycystic disease

Autosomal Dominant
Autosomal Recessive

Effect of Polycystic disease on LFTs?

Usually normal

Which type of polycystic disease is more aggressive - recessive or dominant?

Recessive

Recessive polycystic disease has association with:

hepatic fibrosis, portal hypertension

In dominant polycystic disease, what % of patients have liver cysts?

54-74%

Autosomal recessive polycystic disease presents itself

very early, in infants

Autosomal dominant polycystic disease usually presents

in adulthood

APKD

Adult Polycystic Kidney Disease

Occurence of adult polycystic disease

1:1000 (rare)

APKD prevelance

4:1 females to males

Adult Polycystic Kidney Disease usually detected at this age:

50-70 years

APKD may also involve these organs:

Kidneys, spleen, pancreas, ovaries, testicles

Correlation between severity of renal disease and # of liver cysts?

NO correlation

What % of patients with liver cysts also have renal cysts?

over 50%

Biliary Hamartoma

Solid focal mass composed of bile duct tissue

Biliary hamartomas benign or malignant?

Usually benign, but hamartomas can change from benign to malignant.

Biliary hamartoma sonographic appearance

single, multiple or innumerable
well defined, solid
ring down from cholesterol crystals
bright foci

Biliary hamartoma often mistaken for

METS

Treatment for Cysts

surgical removal or ablation (if symptomatic)

Treatment for Partial Agenesis

None Required

Treatment for Prebiliary Cysts

Surgery if obstruction present

Treatment for Polycystic Disease

Transplant

Treatment for Situs Inversus

None

Treatment for Diaghragmatic Hernias

Surgery

Treatment for Omphalocele

Surgery

Treatment for Accessory Fissures

Non required

Treatment for Hamartoma

Surgical Removal

Treatment for Complete Agenesis

Transplant

Diffuse Hepatocellular Disease

disease process that affects hepatocytes and interferes with liver function

4 types of diffuse liver disease:

1. Fatty Infiltration
2. Cirrhosis
3. Glycogen Storage Disease
4. Hepatitis (Infectious)

Fatty Infiltration

acquired, results in accumulation/deposition of fatty triglycerides with the liver cells secondary to cell injury or impaired fat metabolism from systemic disorders

Is fatty infiltration reversible?

Yes

Fatty Infiltration is associated with

diabetes mellitus
ethanol abuse
obesity
gastric bypass
chemotherapy
& many other diseases

Lab values of moderate-severe fatty infiltration

Elevated LFTs
Elevated Bilirubin

lab values of Mild fatty infiltration

Normal

Clinical Presentation of Fatty Infiltration

Usually asymptomatic
Mild hepatomegaly
Lab values vary depending on severity

Appearance of Mild grade fatty infiltration

slightly diffuse increase in the fine echoes in parenchyma
can see the diaphragm and hepatic veins normally

Appearance of moderate fatty infiltration

diffuse increase in fine echoes with slightly impaired visualization of intrahepatic vessels and diaphragm

Appearance of severe fatty infiltration

marked increase in fine echoes, no intrahepatic vessels or diaphragm seen

Focal fatty infiltration results in

non-uniform areas of increased echogenicity and attenuation within otherwise normal liver texture

Focal Fatty Sparing

focal area of normal liver tissue that has been spared from fatty infiltration. focal normal section of liver in an otherwise fatty infiltrated liver. (island of normal tissue in sea of fatty infiltration)

Focal fatty sparing commonly appears as

hypoechoic liver texture in the medial segment of left lobe anterior to porta hepatis

Cirrhosis

diffuse process characterized by fibrosis and conversion of normal liver architecture into strucxturally abnormal nodules

Essential feature of cirrhosis

generalized involvement of liver by parenchymal necrosis, regeneration and diffuse fibrosis

Scarring caused by cirrhosis is

irreversible and often progressive

Cirrhosis is the #__ cause of death in the US

6th

60-70% of cirrhosis cases in the Western hemisphere are secondary to

Alcohol Abuse

Cirrhosis causes / leads to:

liver cell failure
portal hypertension
leads to caput medussae
varices
GI Bleeding

It is not uncommon for patients with cirrhosis to have

HCC - hepatocellular carcinoma

Caput Medussae

Enlarged abdominal veins

Cirrhosis starts asymptomatic and progresses to

1. abnormal LFTS
2. elevated biliruben
3. elevated Alkaline Phosphatase
4. Hepatomegaly (early stages)
5. Jaundice (yellow skin)
6. Ascites
7. Portal Hypertension Symptoms
8. May have no symptoms

Most common cause of cirrhosis in Eastern Hemisphere

Biliary Disease

Various Causes for cirrhosis

alcohol
drugs
viruses
heredity

Diagnosis of Cirrhosis is made by

blood test
imaging
liver biopsy

Early stage sono appearance of cirrhosis

hepatomegaly
fatty infiltration with increase in liver echogenicity and sound attenuation

Later stage appearance of sono appearance cirrhosis:

1. smaller heterogenous liver
2. relative caudate enlargement
3. echogenic coarse liver texture w/ poss IVC compression
4. ascites
5. may see HCC
6. doppler consistent with PVH

With chronic cirrhosis, may see hepatofugal flow b/c...

the PV blood cannot pass through the liver due to extensive fibrosis

WIth chronic cirrhosis, flow will back up into the____ causing ____

PV system causing venous congestion

With chronic cirrhosis, the size of the PV will exceed

13 cm

With chronic cirrhosis, varices can...

rupture & cause death, especially in alcholics

In chronic cirrhosis, these may be seen on Doppler:

collaterals

In chronic cirrhosis, this can prevent espophageal varices

recannalization of paraumbilical vein

In chronic cirrhosis, may see this tangle of worms appearance

Carvernous Transformation of PV

With chronic cirrhosis may see increased flow in the

Hepatic Artery

Jaundice

condition which causes the skin and sclera of the eyes to turn yellow due to back up if biliruben in the blood

How do you determine amt of jaundice in dark skinned people?

look at sclera of eye

Glycogen Storage Disease

Autosomal recessive genetic disorder of carbohydrate metabolism characterized by a derangement of either the synthesis or degradation of glycogen and its utilization

Type 1 glycogen storage disease AKA

Von Gierke's Disease

Most common type of Glycogen Storage Disease

Type 1

Where does excessive glycogen accumulate with Glycogen Storage Disease?

hepatocytes
kidneys
intestines

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